Provider Demographics
NPI:1053981571
Name:CLARK, EMILY JOSEPHINE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:JOSEPHINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MILLERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44654-1464
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 HILLSIDE DR
Practice Address - Street 2:
Practice Address - City:MILLERSBURG
Practice Address - State:OH
Practice Address - Zip Code:44654-1464
Practice Address - Country:US
Practice Address - Phone:440-225-5180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND.20211616-SP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist